Nasopharyngeal Airway
A nasopharyngeal airway (NPA) is a thin, clear, flexible tube that is inserted into a patient’s nostril. The purpose of the NPA is to bypass upper airway obstruction at the level of the nose, nasopharynx or base of the tongue. It also prevents the tongue falling backward on the pharyngeal wall to prevent obstruction. NPA’s maintain airway patency in patients who are conscious or semi-conscious, they can be used in neonates to adults.
The aim of this Clinical Guideline (CG) is to provide a framework for the insertion and management of NPA’s to relieve airway obstruction, in a self-ventilating patient within a medical ward setting and/or for surgical patients postoperatively in the Post Anaesthetic Care Unit (PACU) and surgical ward.
NPA: Nasopharyngeal airway; is a soft, anatomically designed airway adjunct inserted into the nasal passageway to provide airway patency.
Upper Airway Obstruction: Upper airway obstruction above the level of the larynx results in a failure of airflow into the lungs, despite adequate inspiratory effort. Increasing respiratory effort can worsen the obstruction, as increased intra-thoracic pressure collapses the soft tissue structures inwards.
OSA:
Obstructive Sleep Apnoea
PACU:
Post Anaesthetic Care Unit
OT:
Operating Theatre
EMR:
Electronic Medical Record
ENT: Ear, Nose, Throat
Micrognathia: is a condition in which the jaw is undersized. It is a symptom of a variety of craniofacial conditions. Sometimes called mandibular hypoplasia
Glossoptosis: An abnormal posterior placement of the tongue, which may occlude the airway
WOB: work of breathing
PPE: Personal Protective Equipment
Stertor: noisy, snoring-like breathing resulting from obstruction in the naso- or oropharynx
Indications for insertion of NPA (Medical Patients)
MEDICAL PATIENTS:
A patient’s bed card team should determine whether a NPA is required and order accordingly, ensuring the appropriate size and length are included.
Common indications for patient’s in a ward setting:
Respiratory
distress from upper airway obstructions and increased WOB
Airway
obstruction/obstructive episodes noted by medical, nursing, or allied health
staff
Airway
complications with episodes of mild stertor, causing a decrease in Sp02
Significant
respiratory distress, further evidenced by hypercapnia on blood gas results
Indications
for insertion of NPA (Surgical Patients)
Elective Nasopharyngeal Airway Insertion:
NPA’s are inserted at the end of surgery when the patient is anaesthetised. This enables the NPA to be inserted under direct vision to the correct length.
NPA’s are commonly inserted electively at the end of surgery to prevent problems with postoperative airway obstruction, including:
Micrognathia
associated with congenital syndromes ie. Pierre Robin sequence, Treacher
Collins, Stickler Syndrome
Children
with muscular dystrophy or other syndromes affecting the airway (ie.
Velocardiofacial syndrome, Stickler syndrome, Treacher Collins Syndrome, CHARGE
association, Trisomy 21)
Children
who have pre-existing OSA and children post operatively where upper airway
structures are expected to become swollen (ie. Adenotonsillectomy, palate
repair, pharyngoplasty, tongue surgery )
Children
who required a NPA to maintain airway patency at any point prior to their
surgery
Children
who develop airway obstruction with loss of pharyngeal tone following induction
of anaesthesia
Children who have a NPA inserted intra/postoperatively, generally only require it for the first postoperative night. It is then removed the next day as directed by the bed card team.
Insertion postoperatively in PACU:
Airway
complications postoperatively from episodes of mild stertor, causing a decrease
in Sp02, requiring intervention
Obstructive
episodes noted by medical, nursing, or allied health staff
Significant
respiratory distress and work of breathing, further evidenced by hypercapnia on
blood gas results
If an NPA is accidentally removed, reinsertion should only be done after consultation with surgical team, to avoid damaging the operative site.
Contraindications for insertion:
(ward setting only, does not inc lude NPA’s inserted in surgical patients in OT/Recovery)
Bleeding
disorders
Nasal or
cranial trauma (ie. recent palatal surgery – risk of damage to surgical site(s)
Newborn
septal deviation
Nasal
polyps
Craniofacial
abnormality
Assessment
Ensure
necessary equipment is setup at patient bedside
Functioning
suction equipment
Yankeur
sucker
Appropriate
sized suction catheters
Oxygen
and correct size face mask
Record
patient’s NPA size
Suction
catheter size
Suction
depth measured and recorded (ruler for depth of suctioning required at bedside
to enable easy measurement of suction catheter when suctioning)
Spare NPA
(of the same size insitu and one size smaller)
Brown
Leukoplast rigid tape, 25mm
Check
patency of NPA 1-4/24 according to clinical judgement
NPA’s
inserted on the ward - Planning of ongoing assessment can be made for patients
according to their condition and disease
Ensure
NPA is secure
Assess
integrity of surrounding skin & regularly check tapes
If the
nares are white, the tube needs to re-taped promptly to reduce pressure on the
nostril, or assessment for requirement of a smaller sized NPA
Please
refer to
Nursing
Assessment
Respiratory
Assessment
Ear, Nose
and Throat Assessment
Management
Insertion
/ Re-insertion of a NPA (ward setting only)
A patient’s bed card team should determine whether a NPA is required and order accordingly, ensuring the appropriate size and length are included.
Insertion and Securing of NPA :
Perform
Hand Hygiene
Clean
trolley / work surface with Tuffie wipes
Identify
and gather all equipment for procedure, ensure variable suction equipment is
functioning, leave sterile suction catheter attached but within protective
cover
Select
appropriate size of NP tube
A guide
of measurement is from the lateral aspect of the nares to the tragus of the ear
on the same side
Size is
chosen largely based on length rather than diameter, correct length ensures the
tip sits just above the epiglottis
Prior to
insertion, measure the suction depth of the NPA
Perform
hand hygiene Hand Hygiene
Don
appropriate PPE, including goggles Transmission Based Precautions
Ensure
appropriate positioning Comfort Kids Positioning Posterand consider therapeutic
techniques (see also: Procedure Management Guideline)
Prepare
patient and caregiver, including obtaining consent where possible
Ensure
the patient’s nostrils are clear of secretions, suction if necessary
Moisten
the tip of the NPA tube with sterile water or water based lubricant to ease
insertion
With the
tube tip facing downward, gently insert the tube into a nostril, using a
curving motion to follow the natural path of the floor of the nose.
The tube should pass to just below the level of the soft palate and should be checked with a light and tongue depressor - in case it is too long (causes gagging) or too short (may not bypass the obstruction). If you are unable to insert the NPA, STOP, do not force, and escalate to medical/senior nursing team for assistance.
Secure
the NPA - see Securement of a NPA below
Complete
documentation on patient EMR in ‘flowsheets’ tab under LDA Assessment– see
documentation section
Securement
of a NPA (all settings)
NPA’s need to be secured with tapes, as it is deemed a critical airway. Comfeeltm or similar (Hydracolloid or similar (Hydrocolloid Polyurethane film dressing) is recommended to be used on the patient’s cheeks, to ensure skin integrity is maintained.
Secure by applying brown Leukoplast rigid tape (25mm)/cotton ties around the exposed end of the NP tube and then across the bridge of the nose and onto the closest cheek/s
